Trudy Dehue

A Dutch treat: randomized controlled experimentation and the case of heroin-maintenance in the Netherlands.

In 1995, the Dutch Minister of Health proposed that a randomized clinical trial (RCT) with heroin-maintenance for severe abusers be conducted. It took nearly four years of lengthy debates before the Dutch Parliament consented to the plan. Apart from the idea of prescribing heroin, the minister and her scientific advisers had to defend the quite high material and non-material costs that would arise from employing the randomized controlled design. They argued that the RCT represented the truly scientific approach and was the royal way to unambiguous results. In the present article, I question this common dual justification of RCTs. First, I situate the historical origins and the basic assumptions of the ideal experiment in 20th-century economic liberalism. Secondly, using the Dutch heroin experiment as an example, I discuss human-science experimentation as an attempt to create reality rather than merely record it. Finally, I discuss some surprising responses by heroin users. These responses display the assumptions of RCTs discussed in the historical section, and underline the importance of the culture of heroin use. In the epilogue, I suggest that cultural aspects of heroin consumption can best be studied by thorough ethnographic research.

Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults

438 www.thelancet.com/psychiatry Vol 4 June 2017 within-group variation. Consequently, there is no point in conveying that a child with ADHD has a brain disorder. Moreover, brain scans can only differ and never tell which characteristics should count as a disorder. Rather than that it expresses itself through a wide variety of symptoms, ADHD is the medical framing of wide variety of characteristics. For instance, the youngest children in the classroom appear to have the highest probability to receive the diagnosis because their brains are possibly less developed, which can hardly justify the conclusion of a brain disorder. Remarkably, the study by Hoogman and colleagues mostly offered confirmation of these two conclusions. Apart from large within-group variation, their findings showed no significant differences in the brains of adults with ADHD, which suggests that the minor differences in children largely vanish when they grow up. This finding could have been true headline news in view of the claims by commercial pharma companies and sponsored experts that ADHD is a life-long disorder in need of life-long treatment. Diagnosis of a person with a brain disorder appears not to reduce stigma, and characteristics with biological correlates can still be attributed to a person’s own actions. Biological explanations also create pressure to accept pharmacological solutions. Moreover, it appears to feed the public’s aversion if a disliked characteristic is said to be hardwired. To the degree that diagnoses and biological explanations do provide an initial excuse for the kind of person one is, the most urgent question is why increasing numbers of people apparently need such an excuse. The real stigma rests on deviations from particular standards, as the large body of DSM categories shows. If this stigma can be reduced, less people will require a diagnosis such as ADHD, to the benefit of individuals and society.

Antidepressants and lethal violence in the Netherlands

Dear Editor, Bouvy and Liem’s article correlating antidepressant usage and violence in the Netherlands offers a good example of the hazards of making inferences from broad-brush epidemiological data (Bouvy and Liem 2012). In the late 1960s, the tobacco companies produced a series of graphs showing rising life expectancies, along with falling rates of death from respiratory causes, coinciding with rising cigarette consumption. Spurious inferences of causality or the lack of it from epidemiological correlations such as these are generally regarded as instances of an ecological fallacy. In the tobacco case, they were part of a campaign that is now well-known under the rubric ‘doubt is our product’. One could offer many correlations to point out the flaw in taking such an approach. For instance, alcohol is linked to violence. Its use has increased in the Netherlands during this period, yet rates of violence have fallen. Is there any reason to think that increased alcohol use is less likely than increased antidepressant use to have led to reduced rates of violence? It can be noted that a large proportion of school shootings in the USA and elsewhere have involved perpetrators on an antidepressant but not on alcohol. Another example is that SSRI antidepressants suppress growth in children, but the average heights in Holland have continued to rise during the period 1994–2008. In winter 2009, the Dutch television program Tros Radar asked users of antidepressants to report their experiences. By the end of January 2010, 11,000 responses were received. A number of them were positive, but there were many negative reports of sudden suicidal ideation and suicides. Moreover, 1,600 people reported sudden destructive thoughts and aggressive behavior towards others. Of those cases 54 % were about hurting other people or creating dangerous situations such as car crashes (Dehue personal observations). This was before the possible relation between antidepressant consumption and aggression was widely discussed in the Dutch media. Bouvy and Liem’s article also makes selective use of evidence linking antidepressants to suicide and violence. The first generation of antidepressants was more effective than SSRIs and was given to melancholic patients at greater risk of suicide than patients given an SSRI. If antidepressants lowered suicide rates, the period from 1960 through to the mid-1980s in which more effective drugs were given to patients at greater risk would be the one to look at. In fact suicide rates rose in most Western countries in line with increasing antidepressant use, but no one claims this offers evidence that antidepressants cause suicides (Reseland et al. 2008). There is a missing link that explains what was happening, namely that autopsy rates rose in this period. Autopsy rates have declined since the early 1980s, and suicide rates have fallen correspondingly—several years before the SSRIs came on stream (Reseland et al. 2008; Kapusta et al. 2011). In addition, after drugs are marketed an increasing proportion of their use stems from chronic rather than acute usage. If the risks of violence and suicide are linked to acute usage, this plateaus and increasing chronic use over time can produce a negative correlation between rates of suicide and D. Healy (*) Department of Psychiatry, Bangor University, Bangor, UK e-mail: David.Healy54@googlemail.com

Book Review: Looking Over the Hedgerow

Here Frank does converge with Illich, whose writings sought to encourage people to bear their own uniqueness. And Frank, in speaking of the daimõn, brings into human science discourse an idea that only James Hillman (1996), to my knowledge, also revived, drawing on Plato: ‘your daimon is the carrier of your destiny’ (p. 8). Following Frank, our common destiny, whatever our individual callings, is to the ‘crazy demand’ to be for the other.